The Mansion at Rosemont.

“On Sunday from 3:00 PM to 5:00 PM, 73 residents were present with no staff certified in first aid, obstructed airway techniques, and CPR. From 5:00 PM to 11:00 PM, only 1 certified staff person was present when at least 2 were required.”

“Direct care staff person A received only 6.12 hours of annual training in 2024. Direct care staff person B received only 2.82 hours. Direct care staff person C received only 7.31 hours. All three fell below the required 12 hours of annual training.”

“Direct care staff persons A, B, and C did not receive required training topics during the 2024 training year including medication self-administration, resident needs assessment, dementia care, infection control, immobility prevention, personal care services, and safe management techniques.”

“Staff person A did not receive training in resident rights, Older Adult Protective Services Act, and falls and accident prevention in 2024. Staff person B did not receive training in emergency preparedness, resident rights, and OAPSA. Staff person C did not receive training in fire safety, emergency preparedness, resident rights, and OAPSA.”

“Poisonous cleaning materials including Spic and Span Disinfecting Spray and Comet Disinfecting Bathroom Cleaner were found in an unlocked, unattended housekeeping cart in the Secured Dementia Care Unit, accessible to residents. SDCU residents had not been assessed as capable of safely using or avoiding poisonous materials.”

“Resident #1 did not receive prescribed Evinity 105mg/1.17ml medication in October 2024, and the home failed to report this medication error to the department within 24 hours as required.”

“Two contractors completing renovations were observed unsupervised in resident room #1, and the home did not have criminal background checks on file for these contractors.”

“Direct care staff person A and B did not receive required annual training during 2023 on meeting residents' needs as described in assessment documents and safe management techniques. This was a repeat violation.”

“Staff person A did not receive required annual training during 2023 in fire safety and resident rights. This was a repeat violation.”

“Unsanitary conditions were observed: the refrigerator and freezer on the lobby level had spills and stains from food, and the vent in the common area bathroom near the laundry room had an accumulation of dust.”

“Exit stairwell #6 had several small black spots covering the walls and brown stains near a pipe opening. On 12/12/24, a missing ceiling tile in the Memory Support unit exposed red and blue wires.”

“The refrigerator and freezer in the kitchenette area on the lobby level did not have thermometers to monitor food storage temperatures.”

“Resident #3's blood glucose readings had multiple transcription errors between the glucometer readings and the medication administration record (MAR) for 12/11/24, indicating improper procedures for medication documentation and security.”

“A bathroom vanity sink in room 170 had a broken lock, leaving toiletry items including Colgate Cavity Protection Toothpaste (labeled as poisonous if swallowed) unlocked, unattended, and accessible to memory care residents who have not all been assessed as capable of safely handling poisonous materials.”

“A shower chair with feces on the seat was observed in the shower of a resident room at approximately 2:45 pm, indicating failure to maintain sanitary conditions.”

“A bottle of prescription strength Selsun Blue Shampoo prescribed to a resident was found unsecured under the resident's bathroom sink, violating procedures for safe storage, access, security, distribution and use of medications.”

“Medication record documentation was deficient: an undated, unsigned medical note from hospice conflicted with the medication administration record regarding dosage and timing instructions for a topical medication, and the resident was no longer on hospice but medication orders had not been updated.”

“A resident was administered a topical medication on the right hip at 20:38 instead of following the prescriber's orders to apply to shoulders and back of neck, as documented in the Location of Administration Report.”

“Direct care staff person A did not receive training in instruction on meeting resident needs as described in the preadmission screening form, assessment tool, and medical evaluation during training year [year].”

“Staff member was verbally and physically aggressive with resident during morning care, including demanding resident get out of bed, refusing assistance, and pushing resident into uncomfortably hot shower. Resident reported being frightened.”

“Staff member A was verbally and physically aggressive and disrespectful with resident during morning care, making statements such as 'get up right now,' 'I'm not gonna help you. I don't care,' and 'Don't touch the handrail,' failing to treat resident with dignity and respect.”

“During the inspection period, 78 residents were present in the facility but no staff persons were present who were certified in first aid, obstructed airway techniques, and CPR, violating the requirement of at least one certified staff person per 50 residents at all times.”

“Staff person B did not receive first day orientation on smoking safety procedures and staff duties and responsibilities during fire drills and emergency evacuation. Staff person C did not receive first day orientation until days after starting. Staff person D did not receive first day orientation until days after starting.”

“Staff person B did not complete training in emergency medical plan within 40 scheduled working hours. Staff person C did not complete training in resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions within 40 scheduled working hours.”

“Direct care staff person A received insufficient annual training in training year [year]. Direct care staff person E received insufficient annual training in training year [year], failing to meet the 12-hour annual training requirement.”